FAILURE TO THRIVE - Flourish Paediatrics

Starship Children’s Health Clinical Guideline 

Note: The electronic version of this guideline is the version currently in use. Any printed version can 

not be assumed to be current. Please remember to read our disclaimer. 

FAILURE TO THRIVE 

• Introduction 

• The Diagnosis 

• Establish the Diagnosis 

• Plan for Admission 

• Planned Multi-Disciplinary Involvement 

• Documentation of Weight Gain 

• Plan for Discharge and Follow Up 

• Prognosis 

Introduction 

Most children with failure to thrive (FTT) are less than 3 years old. The great majority of them do 

not have organic disease. Greater than 80% fail to thrive due to non-organic causes. In this 

context FTT is secondary to inadequate caloric intake. One third of this non-organic FTT is 

accidental, two thirds is non-accidental. Organic disease is responsible for < 20% of cases. Any 

organic disorder if severe enough can impair weight gain and hence cause FTT. Remember, 

coincident non-organic FTT can complicate organic disorders. 

Causes of accidental non-organic FTT include ignorance, poverty and breast feeding failure. Nonaccidental 

non-organic FTT includes more severe and complex conditions such as neglect, 

emotional abuse and Munchausen's syndrome by proxy. 

The Diagnosis 

Failure to thrive is defined as disproportionate failure to gain weight in comparison to height. One 

suggested working definition is “a weight deviation downward from the true percentile (defined as 

the maximum percentile reached between 4-8 weeks of age) crossing two or more percentile lines 

and persisting for more than one month”. Failure to thrive does not mean failure to grow. Weight 

gain is primarily affected, there is less effect on length and minimal effect on head circumference. 

Don't be obsessed by the third centile 

• Most children with weight < 3rd centile do not have FTT. Excluding small but proportionate 

children avoids mislabelling normal children. 

• Don't wait until the third centile is crossed before calling it FTT. Infants can be failing to 

thrive with severe deceleration of weight gain, well before they cross the third centile. 

Principals to Guide Management 

Establish the Diagnosis 

Assess energy and nutrient intake: For formula fed infants ask in detail about how the formula is 

prepared (see New Ethicals OTC section for the manufacturers recommendations re volume of 

water and number of scoops of powdered formula: these vary with formula type) and what else the 

infant drinks, eg. excessive fruit juice intake can result in FTT. For all children obtain a detailed 

history of what is offered and what is consumed in a 24 hour period. 

Assess parent-child attachment: From interaction with you present and from consultation with other 

health professionals in the community who have been involved with the family. 

Author: Dr Cameron Grant Service: General Paediatrics 

Editor: Dr Raewyn Gavin Date Issued: Reviewed June 2005 

Failure to Thrive Page: 1 of 3





Developmental assessment is crucial: With non-organic failure to thrive all milestones are usually 

delayed by the time the infant reaches 4 months of age. Areas dependent upon environmental 

interactions, such as language development and social adaptation, are often disproportionately 

delayed. 

Common physical examination findings in non-organic failure to thrive: 

• Signs of failure to gain weight 

e.g. loss of fat, prominence of 

ribs, muscle wasting 

especially of large groups e.g. 

gluteals 

• Signs of poor hygiene 

• Infant very watchful and alert 

• Infant dislikes being touched or held 

• Lack of stranger anxiety 

• Toddler may indiscriminately seek 

affection 

• Developmental delay • Mild hepatomegaly 

• Apathetic and withdrawn 

behaviour 

• Minimal smiling and 

decreased vocalisation 

• Infant rarely cries but is 

hyperirritable 

• Hypertonia 

• Diminished muscle strength 

• Retention of tonic posturing 

Exclude organic disease: This requires a detailed history and examination. Laboratory 

investigations will add very little unless there are significant findings in the history and examination. 

Investigations that should be considered include: urinalysis (pH, osmolality, cellular elements, 

glucose, ketones), urine culture, stool for ova and parasites, full blood count, erythrocyte 

sedimentation rate, serum urea, creatinine, electrolytes, calcium and phosphorus, total protein, 

albumin, and liver enzymes and coeliac screening. 

Plan for Admission 

Children should be hospitalised for FTT when it persists despite maximisation of community 

support (community nurse, community dietician, social worker, whanau, church, etc.) or because 

characteristics of the child, care giver or family make such outpatient management inappropriate or 

place the child at risk of neglect or injury. 

The three aims of hospitalisation of children with FTT are: 

To observe the child's feeding behaviour and the mother-child interaction 

To see whether the infant's weight gain returns to normal when s/he is provided with adequate 

caloric intake and/or is removed from the family 

To decide whether further laboratory testing is indicated 

Planned Feeding Regimen 

The feeding regimen must be accurately charted and nutritional intake accurately recorded on a 24 

hour fluid balance sheet. The majority of children with FTT will consume > 130 kcal/kg/day. They 

should be offered a caloric intake 50% greater than required for normal growth by a child of the 

same height and of average weight. Average energy requirements are 110 kcal/kg/day for first 6 

months, 100 kcal/kg/day for second 6 months and subsequently to age 3. 

Severity of malnutrition can be determined by calculating the actual weight as a percentage of ideal 

weight for height. Normal is 90 to 110 percent 








Malnutrition: 

Mild = 85 to 90 % of ideal weight for actual height 

Moderate = 75 to 85 percent 

Severe is = < 75 percent 

With non-organic FTT consistent weight gain usually occurs within 2 weeks, occasionally it may 

take up to 3-4 weeks. Usually it will reach 50 g per day. 

Planned Multi-Disciplinary Involvement 

Consultation with the dietician will be helpful in determining severity of malnutrition, estimating 

caloric intake and ensuring appropriate, high calorie diet. FTT in the infant can be a symptom of 

much broader dysfunction affecting the family. Assessment of the family will require consultation 

with the community agencies listed above. During hospitalisation assessment of the mother's and 

the family's emotional and psychiatric health may be necessary. The child and family unit may 

need to be consulted. Social work involvement may be required. Input from other disciplines such 

as Kaitiaki, Pacific family support, lactation specialists, speech therapy and developmental therapy 

will be helpful in some situations. 

Documentation of weight gain 

Weight, length, head circumference and weight-for-height should be plotted on admission. The 

infant should be weighed daily and this weight recorded on daily weight plot. All parameters 

should be documented again prior to discharge. 

Plan for Discharge and Follow Up 

Multi-disciplinary community management is required 

If child not admitted plan follow up with community nurse ± dietician, GP, and CED or outpatient 

clinic. 

If admitted multidisciplinary community co-ordination with discharge planning is essential. Ensure 

communication and follow up between all hospital services and related community agencies has 

occurred. 

eg. Medical staff ↔ general practitioner 

Hospital ↔ community nursing. 

Occupational therapy ↔ visiting developmental therapy 

Kaitiaki ↔ community Maori health services 

Pacific family support ↔ community Pacific health providers 

Prognosis 

There is an increased risk of continued growth retardation. Many children remain small. 

Furthermore, severely impaired growth during the first 6 months of life (controlling for SES and iron 

deficiency) is associated with impaired mental and psychomotor development during the second 

year. The earlier the onset and the greater its severity the worse the outcome. Whether or not 

these changes persist, and how much this persistence is due to adverse social circumstances is 

still uncertain.

FAILURE TO THRIVE - Flourish Paediatrics

Create successful ePaper yourself

Delete template?

Save as template?